Telephone advice for out of hours calls in general practice MARK McCARTHY MARY BOLLAM SUMMARY. Telephone advice in out of hours general practice consultations has been infrequently described in the United Kingdom. Data from 13 general practices (77 doctors) in north London were collected over four-week periods. Of the 970 calls recorded, 86% were managed directly by the practice, and 14% by a deputizing service. The percentage of calls managed by telephone advice varied from 5% to 57% (mean 37%). Use of deputies increased at night, but general practitioners remaining on call maintained their telephone advice rates. In all but one practice trainees also gave telephone advice, but the overall proportion of calls managed by trainees (33%) was lower than that of principals (48%). Children and adults under 60 years, more frequently received telephone advice than elderly patients, as did patients noted by the general practitioners as habitual callers compared with other patients.
Introduction S TUDIES of out of hours visits by general practitioners and comparisons with visits by deputy doctors from a cooperative rota or a commercial service1-3 have shown substantial, and largely unexplained, variations in rates; but they have described the visits, that is the response rather than the requests for care. Differences in the use of telepone advice has been suggested as an explanation for variations in night visiting rates between practices,4 but differences between practices in both visiting and telephone advice have not been studied. Marsh has commented that 'the use of telephone advice is almost undocumented in the UK'.5 This report describes the use of telephone advice during one month in 13 north London practices associated with University College and Middlesex School of Medicine.
Method As part of a study of patients' views of out of hours care,6 59 general practitioner principals and 18 trainees agreed to record data on their out of hours calls in each of the 13 practices. The data were collected during four-week periods between January and June 1986. Data for each patient were recorded by the general practitioners on an A5 card, similar in design to that used by Cubitt and Tobias.7 Items recorded included: the stated reason for the call, whether telephone advice or a visit from the general practitioner or deputy was made, the doctor's assessment of the problem, the treatment and advice given, whether the patient was known to the general practitioner (yes, no or by repute only) and whether the patient habitually called out of hours. The necessity of the call was rated on a five point scale from 1 (absolutely necessary) to 5 (completely unnecessary). The M McCarthy, MRCP, FFCM, senior lecturer and M Bollam,
officer, Department of Community Medicine, University College London. Submitted: 31 March 1989; accepted: 29 May 1989. © British Journal of General Practice, 1990, 40, 19-21.
British Journal of General Practice, January 1990
researcher (M.B.) supervised the return of the cards from the general practitioners on call at night or at the weekend. Data were also obtained about the calls transferred from the practices to four London deputizing services for the same periods. Out of hours calls were defined as being from when the surgery closed in the evening (or Saturday morning) until it reopened in the morning. When surgeries were not open, all the practices had calls intercepted by answering services and rerouted to the duty doctor or to a deputizing service. Some practices would identify the name of the caller from the answering service before deciding whether to accept the call or pass it to the deputizing service. The data were coded, and analysed using SPSS-PC.8 Calls were grouped for analysis: by age (children 0-15, adults 16-59, elderly 60+ years); by time (daytime Saturdays and Sundays 07.00 to 18.59, evenings 19.00 to 22.59, nights 23.00 to 06.59); and by management of the call (general practitioner visit, general practitioner telephone advice or deputy visit). Statistical analysis used chi square tests.
Results A total of 970 calls were made, averaging 74.6 per practice per month and 16.4 per general practitioner principal per month (12.6 per general practitioner including trainees). Practices showed marked differences in call rates. Telephone advice ranged from 5% to 577o of calls, with a mean of 37%; general practitioner visits from 20% to 65% of calls, with a mean of 49%; and deputy visits from no calls to 75%, with a mean of 14% (Table 1). All practices gave telephone advice at some time. Practices with a high use of telephone advice used deputizing services less than practices rarely giving telephone advice. Two of the three practices which never used deputizing services handled more than half of the consultations by telephone, while the other practice gave telephone advice to one in three out of hour callers (Table 1). General practitioner principals answered 580 calls (60%o), trainees 250 (26%o) and deputies 140 (14%o). Although there were Table 1. Management of out of hours calls by practices. % of calls managed by: No. of Total calls per no. of TeleGP Deputy GP in the Practice calls phone visit visit practices A 50 6 44 50 12.5 B 72 32 61 7 8.0 C 54 193 21.4 46 0 D 152 57 43 0 16.9 E 99 35 65 0 11.0 F 21 24 10 67 3.5 G 21 38 48 14 4.2 H 62 53 29 18 10.3 52 1 29 15 56 13.0 J 40 5 20 75 10.0 K 98 28 56 16 19.6 L 38 18 39 42 9.5 M 65 23 65 12 7.2 All 37 963b 49 14 12.2 a General practitioner principals and trainees. b Data missing for seven calls.
M McCarthy and M Bollam
fewer trainee general practitioners than principals, they did relatively more on-call work: 13.9 calls per trainee per month, compared with 9.8 calls per month for principals. Trainees gave telephone advice in all but two practices (Table 2), but they made less use of telephone advice than principals, using it in 33% of the calls they managed compared with 48% (P